Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens.

BACKGROUND: Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain. OBJECTIVE: Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary university hospital. SAMPLE SIZE: 60 patients. PATIENTS AND METHODS: Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand. MAIN OUTCOMES MEASURES: Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0-48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15). RESULTS: The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P=.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4-7]), 8 ([5.75-8]), P<.001, respectively). Those who received IV dexamethasone had less sleep disturbances (P<.001) and higher QoR-15 on day 1 (P<.001) and day 7 (P=.020) postoperatively. CONCLUSIONS: IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15. LIMITATIONS: Single-center study.

Bilateral external oblique intercostal plane block (EOIPB) in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial.

OBJECTIVES: To measure tramadol intake in the first 24 hours post-surgery. In addition, pain scores and quality of recovery were evaluated as secondary outcomes. METHODS: A total of 80 adult patients scheduled for laparoscopic cholecystectomy were randomized into 2 groups (with and without external oblique intercostal plane block [EOIPB]). Control group of patients received standard multimodal analgesia, EOIPB was applied on each side to patients in EOIPB group in addition to multimodal analgesia. The primary outcome was to evaluate tramadol consumption at postoperative 24 hours. Secondary outcomes were evaluating the Numeric Rating Scale (NRS) scores, postoperative Quality of Recovery score (QoR-15), sedation score, the incidence of nausea and vomiting, and antiemetic consumption. RESULTS: In EOIPB group, median (Q1, Q3) tramadol consumption values for 24 hours (0 [0,50] mg) were found to be significantly lower than the control group (50 [50,100] mg) (median difference -50) (p<0.001). NRS values during rest and motion were lower in EOIPB group compared to the control group at all measurement points within 24 hours (p<0.05). The total QoR-15 scores were significantly higher in EOIPB group compared to the control group (p<0.001). No differences were detected in other secondary outcome parameters. CONCLUSION: External oblique intercostal plane block resulted in less postoperative tramadol consumption. However, there were no minimal clinically important differences about postoperative opioid consumption. On the other hand, compared to multimodal analgesia addition of EOIPB improved overall QoR-15 scores at postoperative 24 hours.Clinical Trial Reg. No.: NCT05536557.

A Rare Cause of Epistaxis: Nasopharyngeal Leech Infestation.

Leeches are rare cause of foreign body in airways. A 23-year-old male, experiencing epistaxis and difficulty in swallowing is presented. During nasopharyngoscopy, a moving leech was observed on the nasopharynx posterior wall in midline location, and removal of the leech was decided under general anaesthesia. The flexible nasopharyngoscopy was inserted, but removal was unsuccessful due to the leech's movements. Leeches are blood-sucking parasites, so neuromuscular blocking agent was given to prevent the movement. After administration, motion of the leech was lost and easily removed undamaged. In patients presenting with unexplained epistaxis, hemoptysis, dyspnea, and foreign body sensation in the airway, leech infestation should be included as the differential diagnosis and history of contact with stream water should be questioned. We concluded that use of low dose neuromuscular blocking agents facilitates the gentle removal, and could be necessary for successful management of removal of leech under general anaesthesia.

Efficacy of the Erector Spinae Plane Block for Quality of Recovery in Bariatric Surgery: a Randomized Controlled Trial.

BACKGROUND: Postoperative pain management after bariatric surgery is difficult due to different physiological properties and high sensitivity toward opioids in patients with obesity. It has been reported that erector spinae plane block (ESPB) contributes to postoperative analgesia when applied together with multimodal analgesia. METHODS: Eighty patients were randomized either bilateral ESPB (group E) each side or no block (group C). Our primary aim was to evaluate the effects of ESPB on the quality of recovery 24 h postoperatively in bariatric surgery by using 40-item Quality of Recovery-40 (QoR-40) questionnaire. Postoperative pain assessed using a numerical rating scale (NRS), time of additional analgesic requirement, analgesic consumption, side effects, sedation, mobilization time, and postoperative complications were evaluated as secondary outcomes. RESULTS: Postoperative mean QoR-40 scores were found to be higher in group E (175.02 ± 11.25) than in group C (167.78 ± 18.59) at the postoperative 24th hour (P < 0.05). Pain scores at rest and during movement were higher in group C than in group E. At the postoperative 24th hour, NRS mean SD scores at rest for group C and group E were 3.25 ± 1.32 and 2.40 ± 0.96, respectively. NRS mean SD scores during movement for groups C and E were 3.88 ± 1.49 and 3.12 ± 1.30, respectively. The total amount of tramadol consumed in the first 24 h in group C and group E were mean SD: 86.40 ± 69.60 and 40.00 ± 46.96, respectively; P < 0.05. CONCLUSIONS: ESPB improved postoperative quality of recovery, reduced NRS scores, and total analgesic consumption in patients with obesity undergoing bariatric surgery. CLINICAL TRIAL REGISTRATION: NCT05020379.

The effects of dexamethasone added to ilioinguinal/iliohypogastric nerve (IIN/IHN) block on rebound pain in inguinal hernia surgery: a randomized controlled trial.

PURPOSE: The purpose of the present study was to evaluate the effects of IV dexamethasone added to one single injection Ilioinguinal/Iliohypogastric Nerve (IIN/IHN) block on tramadol consumption and Modified Rebound Pain Score (MRPS) in the first postoperative 24 h in inguinal hernia surgery. METHODS: Five mg IV dexamethasone as an analgesic adjunct in the multimodal analgesia was administered to the patients who were scheduled for Inguinal Hernia Surgery and randomized to Group Dex and normal saline was administered to the patients who were randomized to the Control Group in addition to IIN/IHN Block. Postoperative tramadol consumption, Modified Rebound Pain Score (MRPS), the incidence of Rebound Pain, Rebound Pain time, postoperative 48-h opioid consumption, Numerical Rating Scale (NRS) scores, Quality of Recovery Score (QoR-15), Sleep Quality, and adverse events were evaluated in the patients. RESULTS: The mean scores of MRPS were lower in Group Dex than in the Control Group, both at rest (p = 0.001) and with motion (p = 0.001). Tramadol consumption in the first postoperative 24 h was 45.17 ± 49.59 mg in Group Dex and 95 ± 59.23 mg in the Control Group. The difference between the groups was statistically significant (p < 0.001). CONCLUSIONS: In conclusion, adding IV dexamethasone as a part of multimodal analgesia to IIN/IHN block for inguinal hernia surgery resulted in lower MRPS and lower postoperative opioid (tramadol) consumption. For this reason, IV dexamethasone can be added to the IIN/IHN block after inguinal hernia surgery to reduce the incidence of rebound pain, rebound pain scores, and NRS scores for pain, decrease postoperative opioid consumption, and improve the quality of recovery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: Ref; NCT05172908, Date: December 29, 2021.

Comparing ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach with oblique subcostal transversus abdominis plane block for patients undergoing laparoscopic cholecystectomy: a randomized, controlled trial.

BACKGROUND: Laparoscopic cholecystectomy(LC) causes significant postoperative pain. Oblique subcostal transversus abdominis plane(OSTAP) block was described for postoperative analgesia, especially for upper abdominal surgeries. Modified thoracoabdominal nerves block through perichondrial approach(M-TAPA) block is a new technique defined by the modification of the thoracoabdominal nerves through perichondrial approach (TAPA) block, in which local anesthetics are delivered only to the underside of the perichondral surface. The primary aim of this study was to evaluate the effect of M-TAPA and OSTAP blocks as part of multimodal analgesia on postoperative opioid consumption in patients undergoing LC. METHOD: The present study was designed as a randomized, controlled, prospective study. Seventy-six adult patients undergoing LC were randomly assigned to receive either bilaterally M-TAPA or OSTAP block after the induction of anesthesia and before surgery using bupivacaine 0.25%, 25 ml. The primary outcome was assessed as postoperative 24 h opioid consumption, between groups were compared. Secondary outcomes were Numerical Rational scale(NRS) scores, time to first opioid analgesia, patient recovery, using the Quality of Recovery-15 (QoR-15) scale, nausea and vomiting, sedation score, metoclopramide consumption, and evaluating the analgesic range of dermatome. RESULTS: The mean tramadol consumption at the postoperative 24th hour was higher in the group OSTAP than in group M-TAPA (P = 0.047). NRS movement score at 12th hour was statistically significantly lower in group M-TAPA than in group OSTAP (P = 0.044). Dermatomes showed intense sensory analgesia between T7-11 in both groups, and it was determined that there was proportionally more involvement in the group M-TAPA. There were no differences between the groups in terms of other results. CONCLUSIONS: After the LC surgery, ultrasound-guided M-TAPA block effectively reduced opioid consumption, postoperative pain, and QoR-15 scores similar to OSTAP block. CLINICAL TRIAL REGISTRATION: The study was registered prospectively at clinicaltrials.gov (trial ID: NCT05108129 on 4/11/2021).

Gastric emptying times of obese and non-obese school-aged children after preoperative clear fluid intake: A prospective observational study.

BACKGROUND: Liberal fasting regimens, which support clear fluid intake up to 1 h before surgery in children scheduled for elective surgery, are taking their place in guidelines. However, because of the lack of publications that investigate the gastric emptying time in preoperative obese children, the practice of 1-hour clear fluid fasting in obese children remained at the level of recommendation with weak evidence. AIMS: The primary aim was to investigate whether there is a difference in gastric emptying times between obese and non- obese children after preoperative intake of 3 mL/kg clear liquid containing 5% dextrose by using ultrasound. METHODS: A total of 70 children were included in the study in two groups, 35 obese and 35 non-obese, aged 6-14 years, who were scheduled for elective surgery. The baseline antral cross-sectional area measurements of the children in the groups were made using ultrasound. 3 mL/kg 5% dextrose was consumed. Ultrasound was repeated immediately after fluid intake and every 5 min until the antral cross-sectional area was at the baseline level. RESULTS: The difference in median (IQR [range]) gastric emptying times (minutes) of non-obese {35 [30.0-45.0 (20-60)]} and obese children {35 [30.0-40.0 (25-60)]} were not statistically significant (median of differences 0.0, 95% CI -5.0 to 5.0; p = .563). The antral cross-sectional area and weight-adjusted gastric volumes returned to the baseline level within 60 min after the intake of clear liquid with 3 mL/kg 5% dextrose in all children in both groups. CONCLUSIONS: Obese and non-obese children have similar gastric emptying times, and these groups can be offered clear fluids containing 3 mL/kg 5% dextrose 1 h before the surgery.

Impact of vaccination on the presence and severity of symptoms in hospitalized patients with an infection of the Omicron variant (B.1.1.529) of the SARS-CoV-2 (subvariant BA.1).

OBJECTIVES: The emergence of SARS-CoV-2 variants raised questions about the extent to which vaccines designed in 2020 have remained effective. We aimed to assess whether vaccine status was associated with the severity of Omicron SARS-CoV-2 infection in hospitalized patients. METHODS: We conducted an international, multi-centric, retrospective study in 14 centres (Bulgaria, Croatia, France, and Turkey). We collected data on patients hospitalized for ≥24 hours between 1 December 2021 and 3 March 2022 with PCR-confirmed infection at a time of exclusive Omicron circulation and hospitalization related or not related to the infection. Patients who had received prophylaxis by monoclonal antibodies were excluded. Patients were considered fully vaccinated if they had received at least two injections of either mRNA and/or ChAdOx1-S or one injection of Ad26.CoV2-S vaccines. RESULTS: Among 1215 patients (median age, 73.0 years; interquartile range, 57.0-84.0; 51.3% men), 746 (61.4%) were fully vaccinated. In multivariate analysis, being vaccinated was associated with lower 28-day mortality (Odds Ratio [95% Confidence Interval] (OR [95CI]) = 0.50 [0.32-0.77]), intensive care unit admission (OR [95CI] = 0.40 [0.26-0.62]), and oxygen requirement (OR [95CI] = 0.34 [0.25-0.46]), independent of age and comorbidities. When co-analysing these patients with Omicron infection with 948 patients with Delta infection from a study we recently conducted, Omicron infection was associated with lower 28-day mortality (OR [95CI] = 0.53 [0.37-0.76]), intensive care unit admission (OR [95CI] = 0.19 [0.12-0.28]), and oxygen requirements (OR [95CI] = 0.50 [0.38-0.67]), independent of age, comorbidities, and vaccination status. DISCUSSION: Originally designed vaccines have remained effective on the severity of Omicron SARS-CoV-2 infection. Omicron is associated with a lower risk of severe forms, independent of vaccination and patient characteristics.

The optimum time for intravenous cannulation after induction with sevoflurane in children premedicated with dexmedetomidine.

BACKGROUND: Inhalation anesthesia is a frequently used method for anesthesia induction, especially in young children. No information is available on the optimum time for safe intravenous cannulation after inhalational induction in children with dexmedetomidine premedication. The purpose of the present study was to determine the optimal time for intravenous cannulation after induction of anesthesia with sevoflurane and nitrous oxide in children premedicated with intranasal dexmedetomidine. METHODS: This prospective and observational study was conducted by using the up-down sequential method. Children, who were aged 2-6 years with ASA physical status I, and who underwent inhalation induction for elective surgery were included in the study. Anesthesia was induced with sevoflurane and nitrous oxide after the premedication with intranasal dexmedetomidine (2 mcg/kg). Intravenous cannulation was attempted on the dorsum of the hand by an experienced anesthesiologist 4 min after the loss of the eyelash reflex in the first patient. The procedure was considered successful in patients without any movement, cough, or laryngospasm. The waiting time for cannulation was increased by 15 s if the procedure was not successful in the previous patient, and on the contrary, it was reduced by 15 s if the procedure was successful in the previous patient. The probit test was used in the analysis of up-down sequences. RESULTS: In the present study in which a total of 40 patients were included, the effective cannulation time was found to be 14.40 s (95% confidence limits, 1.30-27.82 s) in 50% of the patients, and the effective cannulation time was found as 84.64 s (95% confidence limits, 69.61-218.26 s) in 95% of the patients. CONCLUSIONS: In conclusion, we suggest that the appropriate time for cannulation is 85 s (1.45 min) after the loss of eyelash reflex in children sedated with dexmedetomidine and induction with sevoflurane and nitrous oxide-oxygen mixture.

Ultrasound-guided bilateral modified-thoracoabdominal nerve block through a perichondrial approach (M-TAPA) in patients undergoing laparoscopic cholecystectomy: a randomized double-blind controlled trial.

BACKGROUND: Modified thoracoabdominal nerve block through the perichondrial approach (M-TAPA) is a new technique that provides effective analgesia of the anterior and lateral thoracoabdominal walls by administering local anesthesia only to the underside of the perichondral surface. The primary purpose of the present study was to investigate the postoperative analgesic efficacy of M-TAPA block performed before surgery in patients undergoing laparoscopic cholecystectomy (LC). METHOD: The present study was designed as a double-blind, randomized, controlled, prospective study. A total of 68 patients were included in the study. In group M-TAPA, M-TAPA block was performed bilaterally after the induction of general anesthesia. No block was performed on the group control. The postoperative pain scores, analgesic use in the first 24 h, antiemetic consumption, sedation, postoperative nausea and vomiting (PONV), and Quality of Recovery-40 (QoR-40) scores were recorded. RESULTS: Pain scores were significantly lower in group M-TAPA than in the group control, both during resting and motion at all times (p < 0.001 at each time point). The total amount of tramadol consumed in the first 24 h was lower in group M-TAPA [median 100 mg, min-max (0-200)] than in the group control (P < 0.001). Postoperative median QoR-40 scores were higher in group M-TAPA compared with the group control (P < 0.001). There were no differences between the groups in terms of other results. CONCLUSION: After the LC surgery, ultrasound-guided M-TAPA block reduced postoperative pain scores and tramadol consumption effectively. It was observed that the quality of recovery was also higher because QoR-40 scores were higher.

Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial.

PURPOSE: The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement. METHODS: This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events. RESULTS: The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001). CONCLUSIONS: The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.

Acute infrarenal abdominal aortic occlusion in a patient with COVID-19.

A high rate of thrombotic complications have been observed in patients infected with COVID-19. These complications are related to increased blood hypercoagulabity, which can cause both venous and arterial thrombosis. We report a case of a 60-year-old man with COVID-19 pneumonia and thrombotic occlusion of the infrarenal abdominal aorta at the time of admission to the hospital. A CT scan showed a crazy-paving pattern in the lungs, consistent with COVID-19. A clinical suspicion of aortic thrombosis was confirmed by CT angiography. Embolectomy was undertaken a few hours later. At the end of the procedure, the patient was taken to the intensive care unit while intubated. The patient then worsened, developing severe renal failure, and died on day 1 after admission to the hospital. A CT scan, which is necessary for diagnosis of COVID-19, and a CT angiography, can be used to diagnose thrombotic events. It should be kept in mind that arterial thrombosis can be present not only in hospitalized COVID-19 patients but also at the time of admission. SIMILAR CASES PUBLSHED: 1.